Newly released audits from the HHS Office of Inspector General allege that two Medicare Advantage plans — HumanaChoice and UnitedHealthcare of Wisconsin — systematically overstated how sick their enrollees were. The watchdog says this practice, known as upcoding, generated almost $180 million in overpayments over a two-year period.
The audits found that the plans frequently submitted diagnosis codes that did not match members' medical records, making patients appear to need more expensive care than they actually received. Medicare Advantage plans are paid based on risk scores, so higher reported health needs translate into higher federal payments.
The OIG reports add to federal scrutiny of Medicare Advantage risk-adjustment practices. The findings are specific to the two plans audited, and the source does not include any response from the insurers.